Citation Nr: 21027436
Decision Date: 05/05/21	Archive Date: 05/05/21

DOCKET NO. 16-62 870
DATE: May 5, 2021

REMANDED

Entitlement to a disability rating in excess of 10 percent for service-connected residuals infectious hepatitis is remanded.

REASONS FOR REMAND

The Veteran served on active duty from September 1975 to February 1977. The Veteran testified at a hearing before the undersigned in January 2020. A transcript of the hearing is associated with the record.

The Board most recently remanded the claim in December 2020 for further development. There has not been substantial compliance with the remand directives and the claim must be remanded again. Stegall v. West, 11 Vet. App. 268 (1998).

The Board is unable to make a final decision on the claim because the February 2021 medical opinion is inadequate. The medical examiner opined that the Veteran's increased fatigue and irregular bowel movements are less likely than not due to his service-connected residuals infectious hepatitis. As the basis of the negative opinion, the examiner reasoned that the Veteran's symptoms were not recently noted in his treatment records. However, there is no evidence in the record that contradicts the Veteran's competent and credible testimony regarding the onset and progression of his symptoms. Furthermore, the Veteran did report he continued to experience fatigue in the February 2021 examination. 

The matters are REMANDED for the following action:

1. Obtain any outstanding VA treatment records and associate those documents with the Veteran's claims file. 

2. After completion of the above, obtain an addendum opinion regarding the current severity of the Veteran's service-connected residuals infectious hepatis. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. The examiner must complete the corresponding VA disability benefits questionnaire (DBQ). 

The examiner must specifically consider the Veteran's sworn testimony that he experienced increased fatigue and irregular bowel movements. The fact that those symptoms are not specifically documented in treatment records cannot be the basis of a negative opinion. 

Copies of all pertinent records must be made available to the examiner for review. If the examiner determines that an opinion cannot be provided without an examination, (or telehealth interview, if an in-person examination is not feasible) then one should be scheduled.  

 

M.E. Larkin

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	S.E. Bresler, Associate Counsel

The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.